Provider Demographics
NPI:1336728823
Name:BALLENGER, KAYLEN MANNING (FNP-C)
Entity Type:Individual
Prefix:
First Name:KAYLEN
Middle Name:MANNING
Last Name:BALLENGER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 E ARBOR AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6103
Mailing Address - Country:US
Mailing Address - Phone:480-641-5400
Mailing Address - Fax:
Practice Address - Street 1:6116 E ARBOR AVE STE 112
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6103
Practice Address - Country:US
Practice Address - Phone:480-641-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-03
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ256185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner